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Alayne Yates, John H. Draeger: Chapter 5. Conduct Disorder, in Gabbard’s Treatments of Psychiatric Disorders, 4th

Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI:

10.1176/appi.books.9781585622986.251561. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part I. Disorders Usually First Diagnosed in Infancy, Childhood, or

Adolescence >

Chapter 5. Conduct Disorder

INTRODUCTION

Although several promising treatments for conduct disorder (CD) are described in this chapter, few

long-term follow-up studies are available. The most successful interventions are those that 1) begin

before the behavioral patterns are well established, 2) generate family cohesion and diminish

delinquent affiliations (Frick 2001; Huey et al. 2000), 3) foster acquisition of skill-based

competencies (Scott 2001), and 4) build a positive working alliance within the first 3 months of

treatment (Florsheim et al. 2000).

GENERAL PRINCIPLES OF TREATMENT

Parent training and community-based interventions are effective treatments for CD (Farmer et al.

2002). Controlled, randomized studies support various cognitive-behavioral and behavioral

interventions and the use of medication in conjunction with an evidence-based psychosocial

treatment program. Family-based and systems of care interventions have also been found to be

effective (McClellan and Werry 2003).

Research studies often yield results that do not match clinical practice (Scott 2001; van de Wiel et

1. 2002). In addition, many past treatment approaches have been found ineffective or even

harmful (Frick 2001; Lilienfeld (2005). Traditional psychotherapy (Sowles and Gill 1970) and

supportive case work (Romig 1976) have not been proven to be effective. Youth with CD may

become more aggressive if they are encouraged to express their feelings before they are able to

differentiate and integrate affects (Lilienfeld 2005). Interventions that enlist delinquent peers

(peer groups, peer counseling, community programs) can result in escalation of delinquency,

substance use, and violence (Dishion et al. 2002).

TRANSFERENCE AND COUNTERTRANSFERENCE

Youth with CD often confront the examiner with bravado or threatening behaviors in an attempt to

control the interview. If the examiner does not have the time or skill to delve beneath the facade,

other diagnoses may be overlooked. For instance, when bipolar adolescents steal, stay up all night,

and are sexually promiscuous, this may be attributed to CD rather than to the underlying process

(Lewis and Yeager 2000).

Transference issues surface rapidly with violent adolescents. Those who feel the most helpless are

the ones most likely to threaten, manipulate, or try to “stonewall” the examiner. Once the

evaluation session begins, the examiner is likely to experience frustration and anxiety, if not anger,

disgust, fear, or loathing, in response to the youth’s demeanor or history of destructive activity.

Regardless of treatment modality, the youth will test the therapist’s ability to maintain appropriate

roles and clear boundaries. It is important to manage countertransference issues because if the

examiner reacts with anger or fear, the youth can become enraged or violent. In addition,

delinquent youth are often skilled at manipulation and potentially able to con the examiner through

minimization, distortion, and denial. Even experienced clinicians have radically revised an

assessment after reading the chart or talking to corrections staff such as parole officers.

PSYCHOSOCIAL TREATMENTS

Foster Placement

In the past, many youths with CD were treated in specialized, highly structured inpatient andPrint: Chapter 5. Conduct Disorder

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residential programs that tried to nurture competence and good choices and to promote a positive

sense of self. More recently, the Centers for Disease Control and Prevention Task Force on

Community Preventive Services (Hahn et al. 2004) recommended a shorter duration of placement

(average duration of 6–7 months rather than 18 months). CD youth would then be discharged to

foster care, with intensive collaboration between program staff and foster families. Measured

outcomes were to include reduction of violence. Longitudinal study of this approach is needed to

determine the mediators of improvement, risk for further deterioration, and duration of benefit.

Family and Parenting Interventions

Eight randomized controlled trials have shown that family and parenting interventions benefit

youth who have CD or a history of delinquent behavior (Woolfenden et al. 2001). Successful

intervention significantly reduces the amount of time spent in institutions and the rate of

subsequent arrests (Woolfenden et al. 2002). Benefits to behavior, parent mental health, family

functioning, peer relations, or school success are yet to be established. Parent training to increase

support and structure readily complements other interventions such as mentoring and educational

counseling (Farmer et al. 2002; Taylor et al. 2000). Functional family therapy (FFT) has been

applied to a wide range of youth and their families in various multiethnic, multicultural contexts

and with preadolescents and adolescents diagnosed with CD, violent acting-out, and substance

abuse (Sexton and Alexander 2000). The basic assumption is that the child’s behavior is functional

at some level, so attempts are made to develop more acceptable behavior that will achieve the

same purpose. Outcome studies suggest that FFT can reduce recidivism between 25% and 60%.

Longitudinal studies are needed to establish whether these improvements persist over time.

Parent Management Training

Parent management training (PMT) is based on social learning theory. It empowers parents,

teaching them to establish rules, negotiate compromises, construct treatment agreements, and

offer appropriate reinforcements for prosocial behavior (Patterson et al. 1982). Parents learn to

identify behaviors that precede aggression and to respond rapidly and directly before an eruption

takes place. PMT aims to modify parents’ use of coercive methods to correct children’s behavior

(Kazdin 2000). Checklists of behaviors (lying, drug use, etc.) measure progress and guide the

treatment process. Treatment efficacy is empirically supported for younger children diagnosed with

childhood-onset CD (Brezinka 2002). PMT can be successfully combined with training in

problem-solving skills for adolescents. However, the high dropout rate and lack of persistent

prosocial behavior even in “improved” youth indicate the need for more study.

Fast Track is a preventive trial program of social skills and anger-control training, academic

tutoring, parent training, and home visitation used in the early grades. Positive social and

behavioral outcomes were seen after 1 and 3 years. Results were related to the mother’s

engagement in the program and her ability to reduce coercive parenting styles. Improvement in

social competence, peer relations, and behavior continued throughout grade school. Follow-up is

planned through high school (Bierman et al. 2004). After-school programs without broader family

participation have been shown to reduce delinquent behavior in middle-school but not in

elementary-school children (Gottfredson et al. 2004). A recent study in the Netherlands (van Manen

et al. 2004) demonstrated that social cognitive training was more successful than social skills

training in improving social behavior and self-control as well as reducing aggressiveness.

Multisystemic Therapy

Multisystemic therapy (MST) is among the best-researched approaches for hard-core delinquent

offenders (Borduin 1999; Henggeler and Sheidow 2003). Multiple randomized trials with serious

juvenile offenders have shown long-term reductions in criminal activity, violent offenses,

drug-related arrests, and incarceration (Henggeler 1999) as well as reduced recidivism

(Woolfenden et al. 2002). The technique, which is based on social/ecological theory, is directed

toward family, school, peers, and the community. A master’s-level case manager implements

strategies for recruiting family members and others who are positive influences in the child’s lifePrint: Chapter 5. Conduct Disorder

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and supports them through available community resources such as mental health, probation, school

social work, specialized classrooms, day treatment, and/or after-school “street” programs and

groups. Case managers have a small caseload and are available to the family 24 hours each day. A

doctoral-level psychologist or psychiatrist provides direct, frequent supervision of the case

manager.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is effective in the treatment of adolescents with depression and

anxiety, and studies support its indirect benefit for CD youth who also present with comorbid

depression or anxiety (Deacon and Abramowitz 2004; Rohde et al. 2004). A meta-analysis found

that CD youth respond positively to the therapeutic alliance within the treatment process (Shirk and

Karver 2003).

Optimal Treatment

Poor outcome for CD is more likely when symptoms emerge prior to age 13 years. This increases

the risk of later serious, violent, and chronic offending by a factor of 2 to 3 (Loeber and Farrington

2000). Good outcome is predicted by less initial severity, fewer symptoms of

attention-deficit/hyperactivity disorder (ADHD), better verbal IQ, higher family socioeconomic

status, and the absence of parents who have antisocial personality disorder (Lahey et al. 2002).

Educational achievement and psychosocial adjustment emerge as important predictors in late

adolescence (Taylor et al. 2000). Optimal treatment should address each of these areas within the

context of the child’s life, borrowing from systems theory, family therapy, learning theories,

psychology, behavioral techniques, physiology, and psychiatry.

The emergence of research-supported and evidence-based psychosocial interventions underscores

the importance of treating children and adolescents with CD in the context of the family and the

community. Best practice emphasizes the recruitment of prosocial influences (MST); training in

parenting skills and problem-solving techniques; and support of the collaboration between families

and professionals.

Even with the best of interventions, hospitalization may occasionally be necessary for dangerous

situations that require “cooling off” or as a safe setting to initiate treatment for major depression,

organicity, substance abuse, or psychosis. Homicidal or suicidal youth can be stabilized and

transferred to less-restrictive community-based programs for longer-term treatment and

educational support (Bennett et al. 2003).

PHARMACOTHERAPY

Pharmacological agents currently used to treat CD are best employed to target symptoms as a part

of a larger treatment process. Stimulants help problems of inattentiveness, distractibility, and

impulsivity; antipsychotic medications treat delusions or, in smaller doses, reduce aggressiveness;

antidepressants treat comorbid depression and anxiety; and mood stabilizers (including lithium)

can significantly reduce sudden or extreme mood fluctuations (Kutcher et al. 2004). Because CD

and substance abuse often occur together, it is easy to confuse the effect of street drugs (e.g.,

irritability, aggression) with symptoms of CD. In fact, youths with CD may request pills because

they can be sold, hoarded, or bartered, and youths may exaggerate symptoms to obtain medication.

Choose medication that is less subject to abuse and prescribe it cautiously, while remembering that

the judicious use of medication as a part of the overall treatment plan can substantially improve the

outcome. If abuse is suspected, medication may be withdrawn, injected, or administered while the

youth is closely observed. Problematic medication abuse–related behaviors should be addressed

within the treatment alliance and through behavioral management. The family and the youth should

know what the medication is, what it is intended to do, and approximately how long the medication

will be needed. Appropriate consent should be obtained after full disclosure of the indications,

alternatives, and benefits versus the known risks and possible side effects.

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Many studies have shown that stimulant medication can reduce antisocial behaviors and aggression

in CD youth with and without ADHD (Kutcher et al. 2004; Lilienfeld 2005; Wolraich et al. 2005).

Stimulants may not be as beneficial in affective aggression or high-frequency aggression as they

are in aggression overall (Gadow et al. 1990). Stimulants are usually well tolerated but are

occasionally associated with side effects such as increased anxiety, agitation, and even depression.

It should be noted that ADHD commonly accompanies CD, and ADHD is the single best predictor of

antisocial personality disorder in adulthood. Effective treatment of the child’s ADHD may prevent

the emergence of antisocial personality later on. Long-term studies are needed to support this

assumption.

Lithium

Lithium does not reduce the symptoms of ADHD, nor does it specifically affect antisocial behavior in

youth with CD (Klein et al. 1997). However, several positive studies support its efficacy in treating

explosive behavior by stabilizing mood (Gerardin et al. 2002; Malone et al. 2000). Lithium may also

decrease aggressive and explosive behavior in medically or neurologically impaired patients with

CD (McDougle et al. 2003). Periodic blood work is necessary to monitor therapeutic levels of

lithium. Lithium is generally well tolerated, but common side effects include nausea, tremor, and

weight gain. Lithium is entirely metabolized in the kidney and may be a useful alternative as a

mood stabilizer if liver enzymes are elevated.

Antidepressants

Tricyclic antidepressants (TCAs) are not generally used to treat depression or anxiety in children

and adolescents because of the negative side-effect profile. Selective serotonin reuptake inhibitors

(SSRIs), on the other hand, have been shown to be effective in the treatment of depression and

various anxiety disorders. Although they are customarily well tolerated, recent reports of suicidal

thoughts early in treatment have led to a U.S. Food and Drug Administration advisory that patients

be monitored for suicidality weekly during the first month of treatment. SSRIs are ineffective for

symptoms of CD alone, but they can successfully treat comorbid depression or anxiety, and this can

favorably affect the symptoms of CD as well (Waxmonsky 2003). Agitation can occur unexpectedly

after long-term use of an SSRI. The agitation resolves readily when the medication is reduced or

stopped. The most common side effects of SSRIs are decreased libido or weight gain. Patients who

are very sensitive to low doses of an SSRI may be “slow metabolizers” who are more likely to

experience side effects; those who are resistant to usual or even high doses may be “rapid

metabolizers” who may not be able to sustain an adequate blood level for a clinical response.

Studies using a microarray chip and DNA samples are under way to determine whether a patient

may be a slow or rapid metabolizer.

Alpha-Adrenergic Agonists

Clonidine has successfully reduced aggressive outbursts in CD in youth with or without ADHD

(Gerardin et al. 2002; Hazell and Stuart 2003), and it is occasionally used in combination with a

stimulant to reduce impulsivity. Research demonstrating the safety and effectiveness of clonidine is

limited, however, although it is believed to increase central gamma-aminobutyric acid (GABA). As

GABA levels increase, aggression tends to decrease in youth with CD. In a recent report, baclofen (a

GABAB agonist) reduced aggressive responses in 10 CD subjects, whereas aggression increased in

the 10 control subjects (Cherek et al. 2002).

Anticonvulsants as Mood Stabilizers

Although carbamazepine is an anticonvulsant, it can reduce aggression in youth who do not have a

seizure disorder (Smith and Perry 1992). Carbamazepine is not recommended for use in children or

youth with CD due to frequent side effects (tiredness, constipation, dry mouth), rare aplastic

anemia, and the absence of appropriate research (Gerardin et al. 2002). Valproic acid (or

divalproex sodium), also an anticonvulsant, effectively improved self-reported impulse control in a

randomized, controlled clinical trial (Rana et al. 2005; Steiner et al. 2003). Topiramate acts as a

mood stabilizer and does not cause weight gain in children and adolescents (Delbello et al. 2005).Print: Chapter 5. Conduct Disorder

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Antipsychotics

The majority of the more than 175 published reports on antipsychotic use in children and

adolescents focus on risperidone (Cheng-Shannon et al. 2004). Low doses of risperidone can reduce

explosiveness and reactive anger in children and adolescents. Side effects include tiredness and

weight gain that may be accompanied by hyperlipidemia and insulin resistance. Weight gain is a

common side effect of antipsychotic medications: olanzapine is the most likely and ziprasidone is

the least likely to cause weight gain. Although the risk of tardive dyskinesia seems much less likely

with the recent (“atypical”) antipsychotics compared to the older (“typical”) ones, there have been

reports of tardive dyskinesia with nearly all antipsychotics. Customary monitoring and clinical

management strategies should be in place when any antipsychotic is prescribed for a youth with

1.  

CONCLUSION

Youth with CD challenge clinicians because of symptom complexity and resistance to treatment.

Over the past 20 years, psychosocial and behavioral interventions have been developed that can

help some extraordinarily difficult youth to live reasonably productive lives. Treatment is often not

successful, however, because of biological factors, comorbidities, inadequate environmental

controls, and family disruption. In the future, longitudinal studies should define the effectiveness of

a growing list of evidence-based treatments. Future research should unravel the complex genetics

that underlie CD and thus facilitate targeted pharmacotherapy. These advances should improve the

outcome for CD youth in the future.

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